Brain areas linked with handling tools respond to images of women in bikinisThey also remember these women’s bodies better than those of fully-clothed womenFuture research could look at if women depersonalize men in certain situations

As a man, who has been known to not immediately avert his eyes from an image of a non-burkha wearing woman, allow me to translate.

Brain areas linked with handling tools respond to images of women in bikinis

Pornography and tool handling are obviously intertwined. If you give a man a hammer, he thinks that just about every woman should be nailed with it.

They also remember these women’s bodies better than those of fully-clothed women

It is difficult to remember what one cannot see. On the other hand, with the proper tailoring much of the physique can be calculated by the astute anatomist.

Future research could look at if women depersonalize men in certain situations

It is scandalous that one could even suggest that these tools of arousal have minds of their own. To believe that, one would have to accept that Chippendales and similar clubs are not just visited by drag queens. These drag queens so good at make up, that the male strippers are unaware that the drag queens they are grinding on – are men. Clearly, the drag queen theory of arousal deserves equal time in the science classroom.

We are still left wondering if the line, She has great eyes, started with the burkha or with the bikini. Perhaps this is going to be used to justify new burkha laws. If the female arousal is shown to be true, in spite of what we all know about sugar and spice (the ingredients for little girls, not the sister act), there will probably be a demand for murkha laws.

Think of the benefit in being a mystery man trying to pick up a mystery woman, or mystery person, or person of mysterious gender. That isn’t a beer belly, I just like to carry my man purse in the front. No need to get a hotel room, since the burkha/murkha hides everything from view. You can now have intercourse right out in public and nobody will be able to prove it. You will have no idea if the person in the other urkha is who you think they are, if they are using protection, or even what their gender is. This will be the dawn of the Promiscuous Age. In the PA, no child will know who Pa is.

The participants, 21 heterosexual male undergraduates at Princeton, took questionnaires to determine whether they harbor “benevolent” sexism, which includes the belief that a woman’s place is in the home, or hostile sexism, a more adversarial viewpoint which includes the belief that women attempt to dominate men.

And that isn’t the headline?

If I have only two ways to view women – at the stove, barefoot and pregnant or as castrating termagants – is it a surprise that I choose a third option? Maybe Princeton screens out men with other views on their admissions paperwork.

California’s Good Samaritan Law and the Byzantine California Supreme Court decision,[1] that is an example of legal Three Card Monte, come from GruntDoc and Symptym. Ten gallon hat tip for all of this.

Well, I wasn’t going to be getting to sleep anyway, if this tedious and juvenile attempt at parsing the legislative intent didn’t put me to sleep. Perhaps it is the near toxic dose of caffeine that foiled their attempts at sedating readers of their decisions. The attempts to defy logic are not so easily explained.

First, I am not a lawyer.

Does that matter?

It shouldn’t. The goal of the Good Samaritan Law is simply to encourage people to help others, when professional rescuers are not already there. The extent of the encouragement is to make it difficult to be found at fault, in a law suit, for injuring the person they are trying to help. That’s it. Let me print it right here.

No person who in good faith, and not for compensation, renders emergency care at the scene of an emergency shall be liable for any civil damages resulting from any act or omission. The scene of an emergency shall not include emergency departments and other places where medical care is usually offered.[2]

And I should explain what the emergency was. It seems that the patient was partying with the defendant and others, smoking some marijuana, drinking some alcohol – the usual behavior of a fine upstanding citizen preparing to drive. The patient was not driving, but her car was involved in a crash in Topanga Canyon. A nice ride – when sober. I hesitate to speculate that being stoned and drunk had anything to do with the vehicle leaving the roadway. The Good Samaritan defendant was in another vehicle, why limited the stoned drunk driving, when you can form a caravan. She was also not driving. The second driver pulled over to assist (apparently he is not a lawyer). The defendant went to assist the passenger, pulled her from the vehicle, and did not move her away from the vehicle, although she claims that it was about to explode. The patient suffered an injury to her spine that resulted in paralysis. This decision makes no attempt to determine if pulling the patient from the vehicle has anything to do with the paralysis, whether leaving her in the vehicle would have made a difference. We do not know. The justices were just playing around with how many ways you could provide care dancing on the head of a pin. It’s what some justices think they are supposed to do. No mention is made of whether the justice in the majority were smoking marijuana at the time of the decision. If we were to emulate their reasoning, we might find them guilty of intoxication without any evidence., but by creatively and inconsistently twisting the intent of the possibly related laws.

I could give plenty of examples of the sleight of hand used by those in the majority, but it all boils down to this. They assume that when the word medical is used, or when the law is included in a medical section of the legal code, that is significant. That wording tells us exactly what was in the minds of the legislature. The legislators all think with one mind. They all vote together for exactly the same reasons. How could anyone ever suggest that there is discord in a legislative body. They vary from being elegant in their subtlety to making Dick and Jane books seem cryptic. Fortunately, the justices understand exactly what was in the mind of the legislators – It is not what the legislators wrote.

When these omniscient legislators leave out the word medical, we should not pay any attention to that. The legislators made their intent abundantly clear in vague language elsewhere. Only the interpretation that this is designed to encourage provision of medical care to someone who does not need rescuing, can be drawn from the law.

I will provide one quote from the dissent:

Thus, in the majority’s view, a passerby who, at the risk of his or her own life, saves someone about to perish in a burning building can be sued for incidental injury caused in the rescue, but would be immune for harming the victim during the administration of cardiopulmonary resuscitation out on the sidewalk. A hiker can be sued if, far from other help, he or she causes a broken bone while lifting a fallen comrade up the face of a cliff to safety, but would be immune if, after waiting for another member of the party to effect the rescue, he or she set the broken bone incorrectly. One who dives into swirling waters to retrieve a drowning swimmer can be sued for incidental injury he or she causes while bringing the victim to shore, but is immune for harm he or she produces while thereafter trying to revive the victim.[3]

The justices clearly did consider the contradiction between what the wording and their interpretation of the intent of the legislature. The dissenting justices also found for the plaintiff, but did not agree with the reasoning of the majority. The dissenters felt that the behavior of the defendant, apparently stoned and drunk, was not consistent with her claim that she thought the vehicle was about to blow up.

Now that this is quite clear, you should understand that the first rule of the House of God[4](as modified for pre-hospital use) should be – At the scene of an emergency the first procedure is to take your own pulse call a lawyer for a consultation about whether this is an emergency, whether the emergency is medical, and whether you are trained to the level of an untrained person. In other words, you should film this, because a person dying on film could be worth some money to you. If you do anything that is not medical, but is an attempt to help, you should expect to pay money to anybody who might have an injury. At least, if you have any money left after paying for all of the lawyers.

I received my basic EMT and paramedic training in California. Nobody ever suggested such an interpretation of the Good Samaritan Law in any of my training. Our training was to help people. The specifically idiotic parts of the EMS law did receive special attention.

The Good Samaritan Law was written by a bunch of politicians. Suggesting that they were so careful in their wording in one place for a specific reason, while their vague wording in another place has no specific reasoning is ridiculous. The idea that they were thinking along these lines, these are the same politicians who write all of the other laws in California, is giving them too much credit. The law was written to encourage by-standers to help. As interpreted by this court, it has the opposite meaning – Do not help.

This week, again, there is no theme. Read the rest of the NSR Blog posts at NSR Week 14.

This continues from Part I, Part II, and Part III. One of the problems with people claiming that naloxone is diagnostic, or that there is something to be gained by drawing conclusions from a response to naloxone, is that it is just bad logic.

How many white swans does one need to observe before inferring that all swans are white and that there are no black swans? Hundreds? Thousands? The problem is that we do not know where to start[1]

–

While we do not care that much about swans in EMS, the occasional dying swan act is just something we occasionally need to deal with. The problem of drawing inappropriate conclusions may be our biggest problem. Claiming that naloxone is diagnostic is not any different from claiming that all swans are white.

I have seen many swans.

OK.

They were all white.

Still OK.

Therefore all swans are white.

That may be true, but there is no way that we can prove this.

How many swans do we need to see to be able to draw this conclusion?

All of them.

–

Not 51%.

–

Not 90%.

–

Not 99%.

–

Not 99 and 44/100ths%.

–

Not 99.999%.

–

We need to see all of them.

So we round up all of the swans in the world and observe that they are all white. Then we are sure.

No.

Still not OK.

We also have to examine all past swans and all future swans.

There may have been a species of non-white swans that became extinct.

There may be a genetic mutation, or there may be genetic manipulation, that would lead to a non-white swan.

Therefore, how many administrations of naloxone to opioid-free people do you need to observe – without response – to be able to state that naloxone is diagnostic for opioids?

All of them.

All in the past.

All in the future.

We can conclude that it seems that naloxone is a way of identifying opioid consumers, but that we reserve judgment on something that cannot be proven.

So there is no way to prove this?

That’s right.

But there is a way to disprove this.

Why disprove it?

Because bad logic leads us to make mistakes.

In EMS, it is fortunate that we are only playing with patients’ lives. So why worry about making bad decisions? Especially, since this is not a decision likely to kill anyone?

Even though this is not likely to kill anyone, similar logic is not so benign.

So, how do we disprove something like this?

How many non-white swans would it take to prove that not all swans are white?

At least one.

It is such a fragile and useless conclusion, that to disprove it requires one and only one example of failure of the supposed rule.

An exception does not confirm a rule. An exception demonstrates that the rule is faulty.[2]

Farther down in the same paragraph, Dr. Taleb provides the answer –

Note that the Black Swan is not just a metaphor: until the discovery of Australia common belief held that all swans were white; such belief was shattered with the sighting of the first cygnus atratus.[1]

–

–

How many ways do I need to demonstrate that it is foolish to conclude what a person may have consumed based on their apparent response to a medication – a medication that has a long history of being wrong?

Well the patients who were postictal (recovering from a seizure) were clearly not patients who should have received naloxone.

Is that because a competent assessment is better at diagnosing the presence of opioids?

That eliminates any reason for using naloxone diagnostically, doesn’t it?

Seizures can occur secondary to opioid use. Stroke/TIA (Transient Ischemic Attack) can also appear to respond to naloxone without any opioid consumption. Alcohol can respond to naloxone. Clonidine can respond to naloxone. These are not opioids.

Squirting naloxone in the veins, muscles, nares, tongue, . . . of every unconscious person does not diagnose the cause of unconsciousness.

This drug abuse (abuse of naloxone by EMS) may mislead us.

If we give naloxone to a person who had a seizure, the patient appears to respond, and we then decide to treat the patient as a drug addict, is there a possibility for harm to the patient? Aren’t we supposed to treat seizure patients for seizure, rather than for an imaginary drug overdose?

If we give naloxone to a person who had a stroke, the patient appears to respond, and we then decide to treat the patient as a drug addict, is there a possibility for harm to the patient?

All this is doing is teaching us, or reinforcing, bad diagnostic skills.

Aren’t we supposed to be doing just the opposite?

Science is only valid if there is a way of disproving the hypothesis. Anything that cannot be disproved is not science. This use of naloxone to diagnose is not science. This use of naloxone to diagnose is pseudoscience and needs to be opposed.

Heroin overdoses can be reversed with naloxone.[1] This much is understood.

A reason for being aware of the effects of naloxone is that HOD (Heroin OverDose) is not always simple. Often the user does not know what he took. The mystery drug may have been sold to him as heroin, but there is not much quality oversight in the illegal drug trade. Many of the health problems related to heroin use actually come from adulterants mixed with what they inject as heroin. So the user may have injected what he thought was heroin. You may be told that he injected heroin. Although the patient may present with pinpoint pupils, respiratory depression, and altered mental status, the heroin might be a cocktail that only contains a little heroin, contains no heroin at all, or contains an opioid that does not respond to naloxone the way that heroin responds to naloxone.

At our poison control center, xylazine, an alpha-2 adrenergic agonist which may produce pupil constriction and somnolence mimicking heroin effects, has also been found as an occasional contaminant of heroin. Most recently, clenbuterol, a long-acting beta-2 adrenergic agonist, has again surfaced in an epidemic of unusual heroin overdoses with symptoms and signs including tachycardia, tremor, diaphoresis, and laboratory findings of hyperglycemia, hypokalemia, and lactic acidosis.[3] and [4] Additionally, quinine has been detected in the urine of heroin abusers presenting with tinnitus.[2]

Heroin is readily available and relatively inexpensive; law enforcement officials and treatment providers believe that heroin may eventually overtake cocaine as the region’s greatest drug threat. The purity level of South American (SA) heroin, the predominant type available in the region, is relatively high but has been gradually decreasing over the past several years. Declining heroin purity has contributed to local abusers’ alternative methods of abuse, including injecting larger doses, injecting more frequently, or abusing heroin along with other drugs, such as fentanyl—practices that pose a greater risk of overdose and death.[3]

Some of the other drugs that have been mixed with heroin, or substituted for heroin, are xylazine, clenbuterol, scopolamine, and fentanyl.

Naloxone has not been effective in reversing the sedation caused by xylazine in several reported cases.[4]

The patient, a 27-year-old farmer, attempted to commit suicide by self-administration of about 75 mL 2% aqueous solution xylazine (Proxylaz/Atarost) by intramuscular injection as a consequence of a conflict situation in his family. He was found to be comatose with narrow pupils and no response to light and pain stimuli.

Clenbuterol is a beta-2 agonist only for use in non-food animals. Xylazine is also not supposed to be used in animals that might be eaten by humans. It appears to have a narrow therapeutic window (the effective dose and toxic dose are very close together), since some of the reports to the FDA are for ineffectiveness, while many of the others are for death. These are reports of veterinary use.[6]<

The examination of 12 morgue cases positive for clenbuterol (11% of the total number of drugrelated deaths during a 3 month period) showed that there were many other drugs in their systems.

Heroin use was confirmed in postmortem specimens from eight of the cases by the presence of 6-acetylmorphine. In each of the other four cases (cases 3, 4, 7, and 11), heroin use by the decedent is strongly supported by the presence of morphine with a documented history of heroin abuse. Multi-drug use was predominant with cocaine present in four cases, fentany present in three cases, ethanol and a benzodiazepine present in two cases, and methadone present in one case. With illicit drug users, many of whom use multiple drugs, it is often not possible to determine the contribution of each individual drug to the cause of death.[7]

Clenbuterol is a a used for weight loss, muscle building, and performance enhancement – not that kind of performance enhancement. It is used to stimulate muscle growth and several athletes have admitted to using it to improve competitiveness. Probably not the goal of heroin addicts.

Clenbuterol is a drug that has a rapid onset, yet lasts several times longer than heroin. Patients in several states came to the hospital after the heroin wore off. Almost all had hypokalemia, hyperglycemia, palpitations, and tachycardia. Most were also hypotensive.[8]

Other adulterants may be opioids that are much less responsive to naloxone. I prefer to give much smaller than standard doses of naloxone. Just enough for the patient to be breathing adequately and somewhat responsive to stimuli. I have no hope to engage in fascinating conversations, take long walks on the beach, or travel with them. I just intend to keep them from deteriorating, clinically.

The possibility of an overdose that requires more than the standard dose of naloxone is real. This is where some judgment has to be applied. If initial small doses of naloxone are ineffective, perhaps larger doses are indicated. The recent fentanyl/heroin overdoses have led to some patients receiving much higher doses of naloxone and still having significant respiratory depression. At that point, maybe even much earlier, you may want to just work on your airway management, any other symptoms (such as hypotension), consider that it might be something more than an overdose, and make him somebody else’s problem transport.

An epidemic of naloxone-resistant heroin overdoses due to fentanyl adulteration has led to significant morbidity and mortality throughout the central and eastern United States. According to records of the Philadelphia County Medical Examiner’s office, at least 250 overdose deaths have been associated with fentanyl between April 1, 2006, and March 1, 2007.[9]

The DEA claims to have shut down production of nonpharmaceutical fentanyl, which may have been a large factor in these overdoses.[10]

These were some cases where the adulterant was only a problem for the user. There are cases where the adulterant is a significant risk for the person administering naloxone. Part of the problem is the increase in the use of opioids that are not responsive to standard doses of naloxone. Not that putting a junkie into withdrawal is safe, but with adulterants there can be a toxic effect covered up by the sedating effects of a heroin overdose.

On March 16, 1995, eight persons were treated in the emergency department (ED) of a Bronx hospital for acute onset of agitation and hallucinations approximately 1 hour after “snorting” heroin. On physical examination, all these persons had clinical manifestations of anticholinergic toxicity (i.e., tachycardia, mild hypertension, dilated pupils, dry skin and mucous membranes, and diminished or absent bowel sounds); five had urinary retention. All were initially lethargic and became agitated and combative after emergency medical service (EMS) personnel treated them with parenteral naloxone, which is routinely used for suspected heroin overdose to reverse the toxic effects of opioids (e.g., coma and respiratory depression). All patients received diazepam or lorazepam for sedation, and signs and symptoms resolved during the next 12-24 hours.[11]

Going from a nice coma to the agitated delirium of scopolamine overdose, in a matter of about a minute, is not my idea of fun. Even if it were, it might not be a popular idea with my partner, the police, or any other person on scene. While a lot of these were taking heroin nasally, not all of them were. Wrestling with someone who has a good chance of sharing hepatitis+ and HIV+ blood is not good risk management. Starting an IV to sedate that person, after wrestling with the person, is also something to be avoided. Sedating the person with a respiratory depressant that powerfully interacts with opioids only complicates matters. It is so much easier to just manage the airway.

I used clonidine as an example of a drug that is not an opioid, yet responds to naloxone. Another way to look at this is by looking at naltrexone.

Naltrexone is a longer acting opioid antagonist, but it is also used in treatment of alcoholism. Are we supposed to believe that alcohol and opioids are the same?

No, but the reason people seem to die from HOD (Heroin OverDose) is from respiratory depression. Opioids have a significant effect on the respiratory drive. The mu (μ) receptor appears to be the major cause of respiratory depression. With large doses of opioids, the brain stem’s respiratory centers become much more tolerant of high concentrations of CO2.

Alcohol seems to have some respiratory depressant effect. Benzodiazepines can have a powerful respiratory depressant effect, as well. Combining either of these with an opioid is more likely to result in significant respiratory depression, or apnea. Naltrexone is expected to have an effect on alcohol use, but not benzodiazepine use. Naloxone also seems to have an effect on alcohol use, but not benzodiazepine use. Still, we are supposed to believe that naloxone does not work on anything that is not an opioid.

Is alcohol an opioid? No. Alcohol may cause stimulation of opioid receptors, but other addictive drugs might be expected to interact with these receptors. Benzodiazepines are addictive, but do not seem to respond to naloxone or naltrexone. So, why alcohol?

The mechanism of action of naltrexone in alcoholism is not understood; however, involvement of the endogenous opioid system is suggested by preclinical data. Naltrexone, an opioid receptor antagonist, competitively binds to such receptors and may block the effects of endogenous opioids. Opioid antagonists have been shown to reduce alcohol consumption by animals, and naltrexone has been shown to reduce alcohol consumption in clinical studies.

Naltrexone is not aversive therapy and does not cause a disulfiram-like reaction either as a result of opiate use or ethanol ingestion.

Naltrexone is a pure opioid receptor antagonist, yet is used for the treatment of alcoholism. Naloxone is also a pure opioid receptor antagonist, yet many claim it has no effect on alcohol.

Way back in 1999, Dr. Karl Sporer wrote a review of HOD. In order to be mysterious, he hid it under the title Acute Heroin Overdose. Here is some of what he wrote. –

The heroin overdose syndrome (sensitivity for diagnosing heroin overdose, 92%; specificity, 76%) consists of abnormal mental status, substantially decreased respiration, and miotic pupils. The response of naloxone does not improve the sensitivity of this diagnosis.[2]

In many heroin-related deaths, morphine levels alone do not account for the fatal outcome.[2]

Multiple drug use is common in heroin-related deaths. Most patients who die of heroin-related causes have significant alcohol (29% to 75%) or benzodiazepine (5% to 12%) levels.[2]

What about responses to naloxone when no opioid is found in the body?

Another series of patients with presumed heroin overdose who responded to naloxone underwent extensive serum quantitative drug testing (58). The clinical variables used to diagnose heroin overdose in this study were not well defined. Of the 53 patients, 45 had clinically significant serum drug levels that were consistent with heroin intoxication, 6 had detectable levels of other opiates, and 2 had no detectable levels of serum opiates.[2]

One study by Hoffman, referred to frequently in the previous paper, looked at 730 patients treated with naloxone. This was back in the dark ages of EMS, in Los Angeles (home of Emergency!), and they apparently gave naloxone to everyone with AMS (Altered Mental Status). Not that things are very different in some places, today. They were trying to find out if the routine administration of naloxone to every AMS patient was necessary. They found that their diagnostic criteria were better than response to naloxone.

AMS with any of the following criteria – respirations less than 13, pinpoint pupils, or circumstantial evidence of drug abuse were compared with response to naloxone.

Six of the 25 complete responders to naloxone (24%) ultimately were proven to have had false-positive responses, as they were not ultimately given a diagnosis of opiate overdose. In four of these patients, the acute episode of AMS was related to a seizure, whereas in two, it was due to head trauma; in none of these cases did the ultimate diagnosis include opiates or any other class of drug overdose (which might have responded directly to naloxone). Thus, what was apparently misinterpreted as a response to naloxone in these cases appears in retrospect to have been due to the natural lightening that occurs with time during the postictal period or after head trauma.[3]

Almost one quarter of the complete responders to naloxone did not have opioids on board. Maybe a bit of this is poor assessment, but what do you expect from people who are trained to believe that response to naloxone indicates opioid overdose?

Easily determined clinical indicators detected 22 of the 24 patients in our study diagnosed as having an opiate overdose, whereas only 21 of them had any response to naloxone (and only 19 had a complete response). The two patients with opiate overdose who were not identified by these clinical findings did not respond to naloxone, suggesting that serial administration of these tests fails to improve sensitivity over that achieved through the use of the clinical findings alone. The study indicates that there is no diagnostic benefit derived from the administration of naloxone to all AMS patients.

In addition, response to naloxone created a substantial amount of diagnostic confusion, as not only were there several false-positives among the complete responders (who fortuitously awoke around the time the naloxone was administered) but also the number of equivocal responders to naloxone was greater than either the number of complete responders or even the total number of patients with opiate overdose. If the clinician interprets these equivocal responses as evidence of opiate overdose, he will be misclassifying most of these patients; interpreting partial response as evidence against opiate overdose further decreases the sensitivity of response to naloxone. Finally, treating partial response as “indeterminate” excludes naloxone response as a potential tool in a group even larger than the small group of opiate overdoses for whom this diagnostic challenge with naloxone is supposed to provide potential benefit.[3]

Apparently the diagnostic value of naloxone response tells you nothing that you didn’t already know about the patient.

Naloxone may mislead you to conclude that you know something about the patient that is not true.

Naloxone is not diagnostic.

naloxone’s value as a possible diagnostic tool for clinicians can be estimated only according to whether it actually helps clinicians in their diagnostic decision making.[3]

Telling someone that you know they took an opioid, because they responded to naloxone, is not using naloxone as they suggest and it may lead to an incorrect diagnosis. In other words, it is an example of misinformation and bad logic. If the police use your statement to charge someone with a crime, but it later turns out that you were not correct, are they going to think that you are so smart? What is the purpose of making this incorrect statement, except to appear to be smart. It might be slander. Fortunately, nobody would ever sue anyone in EMS.

Reciting bad information, to show off how smart you are, is not smart.

We should not be encouraging misinformation in EMS. We have too much of that already. We need to eliminate bad teachings, and this is one.

It seems that naloxone and naltrexone have an effect on non-opioid respiratory depression OR other drugs that cause respiratory depression may be activating the opioid receptors, even in the absence of opioids. Neither of these would encourage me to make the unsupportable statement –

This is not based on any research, otherwise we would have some indication of the specificity, selectivity, or sensitivity of naloxone for the reversal of opioid drugs. Perhaps we should look at the information provided on the FDA label.

There are these sentences, but nothing to support their claim –

Naloxone is an essentially pure opioid antagonist, i.e., it does not possess the “agonistic” or morphine-like properties characteristic of other opioid antagonists. When administered in usual doses and in the absence of opioids or agonistic effects of other opioid antagonists, it exhibits essentially no pharmacologic activity.[1]

A paragraph down from there and they admit –

While the mechanism of action of naloxone is not fully understood, in vitro evidence suggests that naloxone antagonizes opioid effects by competing for the mu, kappa, and sigma opiate receptor sites in the CNS, with the greatest affinity for the mu receptor.[1]

The “mechanism of action of naloxone is not fully understood,” but they are willing to state that “When administered in usual doses and in the absence of opioids or agonistic effects of other opioid antagonists, it exhibits essentially no pharmacologic activity.”

Then they go on to describe its Adjunctive Use in Septic Shock.

Naloxone has been shown in some cases of septic shock to produce a rise in blood pressure that may last up to several hours;[1]

Hmmm. I guess more than one person is responsible for the compilation of the drug label – and they are not allowed to communicate. To me, “exhibits essentially no pharmacologic activity,” would rule out any activity in septic shock, since septic shock is not a sequela of opioid intoxication. A “rise in blood pressure that may last up to several hours,” is not insignificant, regardless of its effect on survival. After all, some of naloxone’s effect on opioid overdose last about the same amount of time with standard IV doses. It would not surprise me to learn that this rise in blood pressure, a rise that last about as long as the expected pharmacologic activity, is an indication of pharmacologic activity.

Let’s go back and look at what they wrote about how it works –

While the mechanism of action of naloxone is not fully understood, in vitro evidence suggests that naloxone antagonizes opioid effects by competing for the mu, kappa, and sigma opiate receptor sites in the CNS, with the greatest affinity for the mu receptor.[1]

After claiming that naloxone works exclusively to reverse the effects of opioids, they demonstrate that this is an illogical and ridiculous thing to assume. The words not fully understood and in vitro evidence suggests do not make a good case for certainty about the effects of naloxone. Then stating that it works, not on one, not on two, but on three different receptor sites in the CNS (Central Nervous System) – the mu (μ) receptor, the kappa (κ) receptor, and the sigma (σ) receptor.

the mu, kappa, and sigma opiate receptor sites in the CNS, with the greatest affinity for the mu receptor.[1]

To suggest that a drug that has such broad effects does nothing other than reverse opioids, well that is just silly. We do not know all of the effects of naloxone. We do not know all of the effects of these receptors

Elsewhere they state, on the topic of Respiratory Depression Due to Other Drugs –

Naloxone is not effective against respiratory depression due to non-opioid drugs and in the management of acute toxicity caused by levopropoxyphene. Reversal of respiratory depression by partial agonists or mixed agonist/antagonists, such as buprenorphine and pentazocine, may be incomplete or require higher doses of naloxone. If an incomplete response occurs, respirations should be mechanically assisted as clinically indicated.[1]

If the FDA is consistent, no other drug should describe reversal of respiratory depression by means of naloxone. I did not wander this far, just to describe one case of the FDA being consistent. One of the well known uses of naloxone is to reverse respiratory depression and other effects of overdose with clonidine (Catapres, Durapres, and others).[2]

Under Overdosage –

Naloxone may be a useful adjunct for the management of clonidine-induced respiratory depression, hypotension and/or coma; blood pressure should be monitored since the administration of naloxone has occasionally resulted in paradoxical hypertension.[2]

Maybe they describe clonidine as an opiod?

Clonidine stimulates alpha-adrenoreceptors in the brain stem. This action results in reduced sympathetic outflow from the central nervous system and in decreases in peripheral resistance, renal vascular resistance, heart rate, and blood pressure.[2]

No mention of mu, kappa, or sigma receptors appears anywhere – just alpha (α) adrenergic receptors in the brain stem to convince the body that it is already overstimulated adrenergically.

Naloxone 2.0 mg intravenously was administered with a rapid and dramatic improvement in the patient’s respiratory effort and rate to 16 breaths/min, regular without apnea. Assisted ventilation and oxygen were discontinued. There was a modest improvement in the patient’s level of consciousness, and an intact gag reflex was present after naloxone administration.[3]

The largest known clonidine overdose and the most effective drug appears to be one that could not work, because clonidine is not an opioid. There is more to write about this, but it is now over 14 hours late for the NSR blog and there is already a lot here.

I’m trying to sit down and relax and enjoy a nice meal. Well planned. Finished a blog post. After eating, the last of the trash goes out for tomorrow’s collection. A nice tender steak, some mushrooms, balsamic vinegar alternating with red wine vinegar while cooking. A variety of chocolates for desert. All while listening to a nice audio book.

In an earlier post, Off Duty CPR in the Middle of the Road, I wrote about the perceived problem of moisture on the ground when shocking a patient. I do not recall what led me to post that now, but I have found some research on the topic. None of these studies found any problems with defibrillating wet patients. They found that the current delivered to the patient was adequate for defibrillation and that it was safe for rescuers to defibrillate the wet patient. Some of these were addressing the conditions that would affect defibrillation of a patient during therapeutic hypothermia with ice water and with saline. The one bit of advice was to dry the chest before applying pads, but that should be obvious. 🙂

Click on each study for it’s abstract. The one without an abstract is an editorial about the study below it.

Only a small difference was measured in the overall defibrillation voltage and current as applied to the electrodes for the different cases. Thus, underwater defibrillation is safe and can be performed effectively.

CONCLUSIONS: Thirty volts may result in some minor sensation by the operator or bystander, but is considered unlikely to be hazardous under these circumstances. The maximum currents were lower than allowed by safety standards. Although defibrillation in a wet environment is not recommended practice, our simulation of a patient and a rescuer/bystander in a wet environment did not show significant risk should circumstances demand it.

Transthoracic defibrillation via AED pads is safe and effective in a wet condition after cooling with ice-cold water in a pig VF cardiac arrest model because ROSC could be achieved in all animals. Thus, this new cooling device needs further exploration in cases of cardiac arrestin humans.

Ignorance is preferable to error; and he is less remote from the truth who believes nothing, than he who believes what is wrong.

- Thomas Jefferson

Notes on the State of Virginia (1781-1783)

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Bigotry and science can have no communication with each other, for science begins where bigotry and absolute certainty end. The scientist believes in proof without certainty, the bigot in certainty without proof. Let us never forget that tyranny most often springs from a fanatical faith in the absoluteness of one’s beliefs.

Ashley Montagu.

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Today we rely less on superstition and tradition than people did in the past, not because we are more rational, but because our understanding of risk enables us to make decisions in a rational mode.

- Peter L. Bernstein

Against the Gods: the remarkable story of risk (1996)

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Mark my word, if and when these preachers get control of the [Republican] party, and they're sure trying to do so, it's going to be a terrible damn problem. Frankly, these people frighten me. Politics and governing demand compromise. But these Christians believe they are acting in the name of God, so they can't and won't compromise. I know, I've tried to deal with them.

Barry Goldwater.

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I think every good Christian ought to kick Falwell right in the ass.

Barry Goldwater

Said in July 1981 in response to Moral Majority founder Jerry Falwell's opposition to the nomination of Sandra Day O'Connor to the Supreme Court, of which Falwell had said, "Every good Christian should be concerned." as quoted in Ed Magnuson, "The Brethren's First Sister," Time Magazine, (20 July, 1981)

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What do you think science is? There's nothing magical about science. It is simply a systematic way for carefully and thoroughly observing nature and using consistent logic to evaluate results. Which part of that exactly do you disagree with? Do you disagree with being thorough? Using careful observation? Being systematic? Or using consistent logic?

Dr. Steven Novella.

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What progress we are making. In the Middle Ages they would have burned me. Now they are content with burning my books.

Sigmund Freud (1933)

Today the samizdat is digital and burning a copy has the opposite meaning. A little later, persecution of the Jews was once again the law - Freud's four sisters all died in concentration camps, although not by burning.

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"Can you prove that it’s impossible?” “No”, I said, “I can’t prove it’s impossible. It’s just very unlikely”. At that he said, “You are very unscientific. If you can’t prove it impossible then how can you say that it’s unlikely?” But that is the way that is scientific. It is scientific only to say what is more likely and what less likely, and not to be proving all the time the possible and impossible. To define what I mean, I might have said to him, "Listen, I mean that from my knowledge of the world that I see around me, I think that it is much more likely that the reports of flying saucers are the results of the known irrational characteristics of terrestrial intelligence than of the unknown rational efforts of extra-terrestrial intelligence." It is just more likely. That is all.

Richard Feynman.

The Character of Physical Law (1965)
chapter 7, “Seeking New Laws,” p. 165-166:

It has been over half century since Feynman explained this. The reports of flying saucers have continued, but there is still no valid evidence to support belief in flying saucers. Feynman's explanation is a good definition of unlikely.

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An ignorant mind is precisely not a spotless, empty vessel, but one that’s filled with the clutter of irrelevant or misleading life experiences, theories, facts, intuitions, strategies, algorithms, heuristics, metaphors, and hunches that regrettably have the look and feel of useful and accurate knowledge.

David Dunning - explaining the Dunning-Kruger effect.

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Treat beliefs not as sacred possessions to be guarded but rather as testable hypotheses to be discarded when the evidence mounts against them.

Philip Tetlock.

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Squatting in between those on the side of reason and evidence and those worshipping superstition and myth is not a better place. It just means you’re halfway to crazy town.

PZ Myers

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The legitimate powers of government extend to such acts only as are injurious to others. But it does me no injury for my neighbour to say there are twenty gods, or no god. It neither picks my pocket nor breaks my leg.

Thomas Jefferson.

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Imagine a world in which we are all enlightened by objective truths rather than offended by them.

Neil deGrasse Tyson

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Education is a progressive discovery of our own ignorance.

Will Durant.

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You don't use science to show that you're right,

you use science to become right.

Randall Munroe

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Just because science doesn't know everything doesn't mean you can fill in the gaps with whatever fairy tale most appeals to you.

There appears to be in mankind an unacceptable prejudice in favor of ancient customs and habitudes which allows practices to continue long after the circumstances, which formerly made them useful, cease to exist

Benjamin Franklin.

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If science proves some belief of Buddhism wrong,

then Buddhism will have to change.

Tenzin Gyatso, 14th Dalai Lama.

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Ridicule is the only weapon which can be used against unintelligible propositions. Ideas must be distinct before reason can act upon them;

Thomas Jefferson.

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Science doesn't make it impossible to believe in God.

It just makes it possible to not believe in God.

Stephen Weinberg.

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There are no forbidden questions in science,

no matters too sensitive or delicate to be probed,

no sacred truths.

Carl Sagan.

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The legitimate powers of government extend to such acts only as are injurious to others. But it does me no injury for my neighbour to say there are twenty gods, or no god. It neither picks my pocket nor breaks my leg.

Thomas Jefferson.

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It is better to not understand something true,
than to understand something false.

Neils Bohr.

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God does not play dice with the universe.

Albert Einstein

Stop telling God what to do with his dice.

response by Neils Bohr.

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All things are poison and nothing is without poison, only the dose permits something not to be poisonous.

Paracelsus.

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What is not true, as everyone knows, is always immensely more fascinating and satisfying to the vast majority of men than what is true.

H.L. Mencken.

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Every valuable human being must be a radical and a rebel, for what he must aim at is to make things better than they are.

Niels Bohr.

-

How wonderful that we have met with a paradox. Now we have some hope of making progress.

Niels Bohr.

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An expert is a man who has made all the mistakes which can be made in a very narrow field.

Niels Bohr.

-

Every sentence I utter must be understood not as an affirmation, but as a question.

Niels Bohr.

-

Some subjects are so serious that one can only joke about them.

Niels Bohr.

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I have no special talents. I am only passionately curious.

Albert Einstein.

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Few people are capable of expressing with equanimity opinions which differ from the prejudices of their social environment. Most people are even incapable of forming such opinions.

Albert Einstein.

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Never memorize what you can look up in books.

Albert Einstein.

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The prestige of government has undoubtedly been lowered considerably by the prohibition law. For nothing is more destructive of respect for the government and the law of the land than passing laws which cannot be enforced. It is an open secret that the dangerous increase of crime in the United States is closely connected with this.

Albert Einstein.

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the chance is high that the truth lies in the fashionable direction. But, on the off-chance that it is in another direction - a direction obvious from an unfashionable view of field theory - who will find it? Only someone who has sacrificed himself by teaching himself quantum electrodynamics from a peculiar and unusual point of view; one that he may have to invent for himself. I say sacrificed himself because he most likely will get nothing from it, because the truth may lie in another direction, perhaps even the fashionable one.

If you've made up your mind to test a theory, or you want to explain some idea, you should always decide to publish it whichever way it comes out. If we only publish results of a certain kind, we can make the argument look good. We must publish both kinds of results.

If a reasonable launch schedule is to be maintained, engineering often cannot be done fast enough to keep up with the expectations of originally conservative certification criteria designed to guarantee a very safe vehicle. In these situations, subtly, and often with apparently logical arguments, the criteria are altered so that flights may still be certified in time. They therefore fly in a relatively unsafe condition, with a chance of failure of the order of a percent (it is difficult to be more accurate).

Official management, on the other hand, claims to believe the probability of failure is a thousand times less. One reason for this may be an attempt to assure the government of NASA perfection and success in order to ensure the supply of funds. The other may be that they sincerely believed it to be true, demonstrating an almost incredible lack of communication between themselves and their working engineers.

Science is a way of trying not to fool yourself. The first principle is that you must not fool yourself, and you are the easiest person to fool.

Richard Feynman.

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Science alone of all the subjects contains within itself the lesson of the danger of belief in the infallibility of the greatest teachers in the preceding generation ... Learn from science that you must doubt the experts. As a matter of fact, I can also define science another way:

Science is the belief in the ignorance of experts.

Richard Feynman.

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The only way to have real success in science, the field I’m familiar with, is to describe the evidence very carefully without regard to the way you feel it should be. If you have a theory, you must try to explain what’s good and what’s bad about it equally. In science, you learn a kind of standard integrity and honesty.

Richard Feynman.

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Some people say, "How can you live without knowing?" I do not know what they mean. I always live without knowing. That is easy. How you get to know is what I want to know.

Richard Feynman.

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I don't know anything, but I do know that everything is interesting if you go into it deeply enough.

Richard Feynman.

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So, to test the prevailing intellectual standards, I decided to try a modest (though admittedly uncontrolled) experiment: Would a leading North American journal of cultural studies . . . publish an article liberally salted with nonsense if (a) it sounded good and (b) it flattered the editors' ideological preconceptions?

Common sense in matters medical is rare, and is usually in inverse ratio to the degree of education.

William Osler.

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The greater the ignorance the greater the dogmatism.

William Osler.

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The desire to take medicine is perhaps the greatest feature which distinguishes man from animals.

William Osler.

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One of the first duties of the physician is to educate the masses not to take medicine.

William Osler.

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In the fields of observation chance favors only the prepared mind.

Louis Pasteur.

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Science knows no country, because knowledge belongs to humanity, and is the torch which illuminates the world. Science is the highest personification of the nation because that nation will remain the first which carries the furthest the works of thought and intelligence.

Louis Pasteur.

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Not far from the invention of fire must rank the invention of doubt.

Thomas Henry Huxley.

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The great tragedy of Science — the slaying of a beautiful hypothesis by an ugly fact.

Thomas Henry Huxley.

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The foundation of morality is to have done, once and for all, with lying; to give up pretending to believe that for which there is no evidence, and repeating unintelligible propositions about things beyond the possibilities of knowledge.

Thomas Henry Huxley.

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My business is to teach my aspirations to conform themselves to fact, not to try and make facts harmonise with my aspirations.

Thomas Henry Huxley.

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There must have been a time, in the beginning, when we could have said – no. But somehow we missed it.

Tom Stoppard

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All men can be criminals, if tempted; all men can be heroes, if inspired.

G. K. Chesterton

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There is no such thing on earth as an uninteresting subject; the only thing that can exist is an uninterested person.

G. K. Chesterton

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Good taste, the last and vilest of human superstitions, has succeeded in silencing us where all the rest have failed.

G. K. Chesterton

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Men become superstitious, not because they have too much imagination, but because they are not aware that they have any.

George Santayana

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If we are uncritical we shall always find what we want: we shall look for, and find, confirmations, and we shall look away from, and not see, whatever might be dangerous to our pet theories. In this way it is only too easy to obtain what appears to be overwhelming evidence in favor of a theory which, if approached critically, would have been refuted.

Karl Popper

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It is difficult to get a man to understand something, when his salary depends upon his not understanding it!

Upton Sinclair

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Freedom is what you do with what's been done to you.

Jean-Paul Sartre

-

Where goods do not cross frontiers, armies will.

Frédéric Bastiat

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The ultimate result of shielding men from the effects of folly is to ﬁll the world with fools.

Herbert Spencer

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Political language — and with variations this is true of all political parties, from Conservatives to Anarchists — is designed to make lies sound truthful and murder respectable, and to give an appearance of solidity to pure wind.

George Orwell

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Facts are stubborn things; and whatever may be our wishes, our inclinations, or the dictates of our passion, they cannot alter the state of facts and evidence.

John Adams

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We're not presuming the answers before we ask the questions.

Lawrence Krauss explaining how science works

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Malo Periculosam Libertatem Quam Quietum Servitium.

Better freedom with danger than peace with slavery.

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Whatever inspiration is, it's born from a continuous "I don't know."

Wislawa Szymborska

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All sorts of torturers, dictators, fanatics, and demagogues struggling for power by way of a few loudly shouted slogans also enjoy their jobs, and they too perform their duties with inventive fervor.

Well, yes, but they "know." They know, and whatever they know is enough for them once and for all.

They don't want to find out about anything else, since that might diminish their arguments' force.

Wislawa Szymborska.

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Theory helps us to bear our ignorance of fact.

George Santayana

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Miracles are propitious accidents, the natural causes of which are too complicated to be readily understood.

George Santayana.

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Fanaticism consists in redoubling your efforts when you have forgotten your aim.

George Santayana

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There is a fundamental difference between religion,

which is based on authority,

and science,

which is based on observation and reason.

Science will win because it works.

Stephen Hawking.

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The truth, indeed, is something that mankind, for some mysterious reason, instinctively dislikes. Every man who tries to tell it is unpopular, and even when, by the sheer strength of his case, he prevails, he is put down as a scoundrel.

H.L. Mencken.

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It is the natural tendency of the ignorant to believe what is not true. In order to overcome that tendency it is not sufficient to exhibit the true; it is also necessary to expose and denounce the false.

I am attempting to make it easier, when I use footnotes, to navigate to the information in a footnote, look at the information, and return to where you were before you clicked on the footnote. If you click on the number of a footnote in the text[1] <- click on the bracketed and underlined number - in this case [1], it will bring the footnote to the top of the screen.

[1] If you click on the bracketed and underlined number of a footnote in footnote section, the [1] at the beginning of this paragraph, it will take you to where you clicked on the footnote in the text, with the footnote along the top of the screen. [To top of footnotes]

If you wish to modify the size of the text, you can press the CTRL key and roll the mouse wheel forward or back, or you can press the CTRL key and the + or - keys to make text larger or smaller. Another way is to adjust the font in your browser controls.

This is a mostly medical blog, so here is the HIPAA incantation to ward off evil whiny HIPAA-obsessed spirits.

HIPAA (Health Insurance Portability and Accountability Act of 1996) is generally misrepresented by those in health care, but there are no violations of HIPAA here. There are some patients I could not discuss without changing details, so details may be omitted, or changed. That may decrease the dramatic effect of some of what I write, but patients are entitled to their privacy and have been since before HIPAA became the ignorant administrators' justification for imitating a two year old yelling NO!

I am not dispensing medical advice. If you get your medical advice off of a blog, instead of consulting a physician (such as your medical director), you probably should not be treating anyone, not even yourself. I could include your dog, but that would suggest that veterinarians do not provide excellent care. The veterinarians I know take pride in the care they deliver and deliver excellent care, more so than many people I know in EMS.

I do point you to research to support what I write, but you still need to make sure that you have the authorization of your medical director before changing any of your treatments. If your medical director does not agree, you can point to the research I write about. Most doctors do understand research, they just have trouble keeping up with the amount of research that is produced.

What I write does not change your protocols. If you do not like a protocol, take it up with the medical director. I have several inadequate protocols, too. I call medical command and attempt to persuade the physician that what I am requesting is in the best interest of the patient. It is rare that I am turned down, but the dose is often inadequate. I call back before I need more, so the patient does not have to put up with the On Line Medical Command delay in treatment. Health care providers should be anticipating where the care of the patient is headed - both for good and for bad.

I do not have any connection to the products I mention, other than using them and being satisfied, dissatisfied, or some combination of the two. If I have any potential conflict of interest, I will mention it clearly.

If I write about a book by an author I know, I will encourage you to buy the book from the author's web site. This means that any money goes to the author (or to where the author wants the money to go, such as a charity) and you have an opportunity to sample the author's writing for free on the author's blog before buying the book.

I may be blunt, but I do not intend it personally. There are few mistakes that can be made that I have not made. I continue to try not to be stupid; you may conclude that I fail.

I welcome any relevant comments and much that is not relevant. I reserve the right to delete any inappropriate comments. I decide what is appropriate based on my own nebulous standards. Criticism of ideas is expected. Criticism of writing style is appreciated.

I avoid obscenity because I believe that the English language provides enough opportunities for creativity that resorting to the words that may not be said on TV (and a growing group of words that may) is unnecessary. I may quote something that contains some of these words, or I may link to something that does, but that is as bad as I expect to be with these words.

On the other hand, you may feel that the ideas I present are offensive. My aim is to encourage thought, dialogue, and creativity - not to tell you everything is OK. You may leave this blog at any time and bury your mind in comfortable, familiar ideas.

If you feel that the ideas I present are not challenging, please encourage me to address whatever you feel I do not adequately address.